- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.50 / $6,686.45 / $6,686.45
| Professional | | $1,346.50 | $6,686.45 | $6,686.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,060.08 / $2,060.08 / $2,060.08
| Facility | | $2,060.08 | $2,060.08 | $2,060.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.69 / $2,060.08 / $2,185.41
| Professional | | $1,335.69 | $2,060.08 | $2,185.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.94 / $2,120.94 / $2,247.27
| Facility | | $1,012.94 | $2,120.94 | $2,247.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.56 / $1,864.04 / $2,688.70
| Professional | | $1,242.56 | $1,864.04 | $2,688.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.35 / $2,139.03 / $3,581.59
| Professional | | $1,733.35 | $2,139.03 | $3,581.59 |